Nutrition and Malnutrition in the Elderly

Goals, Objectives, Standards

Goals Appreciate the scope of nutritional assessment and intervention

in the medical care of the elderly Objectives

Practice use of nutrition screens Practice implementation of nutritional interventions Code correctly for evaluation and treatment

Standards Use DETERMINE nutritional screen Use Mini Nutritional Assessment Compute Body Mass Index Compute Ideal Body Weight Compute Energy Needs Compute Protein Needs

Case Phase 1: Evaluation of Outpatient 82 yr female on a fixed income lives at home

alone and is dependant upon friends as for transportation. She has HTN, CAD, CRF, and OA all modestly controlled on HCTZ, ACE1, TNG, beta-blocker, and acetaminophen. Her chief complaint is having trouble dressing herself secondary to L shoulder pain. You note a 10 pound weight loss since her last visit six months ago.

What do you do next?

Demographics

Malnutrition Independent 0-6% Skilled Care 2-27% Hospital 10-30%, up to 75%

Stay is longer with more malnutrition

MACRONUTRIENTS I

Water 8 x 8 oz/d 30ml/kg/d or 1ml/kcal eaten

Carbohydrates 55-60% total kcal/d ½ carbs from whole grains

Proteins 1 to 1.5 gm/kg/d Fats <30% total kcal/d Cholesterol < 300 mg/d Fiber > 4 gm/d

Macronutrients II

Electrolytes Na <2300 mg/d (1 tsp), <1500 mg/d blacks K K rich foods , >4700 mg/d blacks Mg

Calcium 1200 mg/d Phosphorous 700 mg/d Iron 25-40 mg/d

Micronutrients

Vitamins, Co-factors Minerals Trace Elements

Multivitamin Multivitamin Multivitamin

Anthropometrics I

Clinical 10 pound loss in six months or weight < 100 lbs

Relative Risk of Death 2.0 PPV of malnutrition = 0.99

Minimum Data Set Weight loss >= 5% past month Weight loss >= 10% past six months

Anthropometrics II

BMI : Body mass index = weight (kg) / height (m2) Correlated to nutrition status, morbidity, mortality

18.4 and lower greater risk malnutrition and related diseases 30 and higher the greater risk for DM, CAD, HTN, OA, CA

National Practice Standard = Compute @ each office visit Underweight <18.5 Normal weight 18.5-24.9 Overweight 25-29.9 Obesity >= 30 Extreme Obesity >= 40

BMI Table http://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl2.htmBMI 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35

Height Body Weight (pounds)

58 91 96 100 105 110 115 119 124 129 134 138 143 148 153 158 162 167

59 94 99 104 109 114 119 124 128 133 138 143 148 153 158 163 168 173

60 97 102 107 112 118 123 128 133 138 143 148 153 158 163 168 174 179

61 100 106 111 116 122 127 132 137 143 148 153 158 164 169 174 180 185

62 104 109 115 120 126 131 136 142 147 153 158 164 169 175 180 186 191

63 107 113 118 124 130 135 141 146 152 158 163 169 175 180 186 191 197

64 110 116 122 128 134 140 145 151 157 163 169 174 180 186 192 197 204

65 114 120 126 132 138 144 150 156 162 168 174 180 186 192 198 204 210

66 118 124 130 136 142 148 155 161 167 173 179 186 192 198 204 210 216

67 121 127 134 140 146 153 159 166 172 178 185 191 198 204 211 217 223

68 125 131 138 144 151 158 164 171 177 184 190 197 203 210 216 223 230

69 128 135 142 149 155 162 169 176 182 189 196 203 209 216 223 230 236

70 132 139 146 153 160 167 174 181 188 195 202 209 216 222 229 236 243

71 136 143 150 157 165 172 179 186 193 200 208 215 222 229 236 243 250

72 140 147 154 162 169 177 184 191 199 206 213 221 228 235 242 250 258

73 144 151 159 166 174 182 189 197 204 212 219 227 235 242 250 257 265

74 148 155 163 171 179 186 194 202 210 218 225 233 241 249 256 264 272

75 152 160 168 176 184 192 200 208 216 224 232 240 248 256 264 272 279

76 156 164 172 180 189 197 205 213 221 230 238 246 254 263 271 279 287

BMI: NIH Recommendations

Clinicians should measure BMI and offer obese patients intensive counseling and behavioral interventions.

The National Institutes of Health provides a BMI calculator at www.nhlbisupport.com/bmi and a table at www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.htm.

The Centers for Disease Control and Prevention provides a BMI calculator at www.cdc.gov/nccdphp/dnpa/bmi/calc-bmi.htm.

Anthropometrics III : Research tools Skin fold and mid-arm circumference Water Displacement Bioelectrical Impedance Dual Radiographic Absorptiometry CT MRI Total Body 40K

Wasting and Cachexia Wasting - Severe weight

loss and diminished nutritional intake Semistarvation Reduced metabolic demand Visceral protein sparing Obvious weight loss

RA, CHF, COPD, HIV, Critical care without nutritional support

Cachexia - Inflammatory cytokine mediated wasting

Semistarvation overlap Increased metabolic demand Visceral protein wasting ECF incr masks weight loss Limited response to

antiinflammatory/anabolics Nutritional intervention slows

semistarvation part Marasmus, CA, HIV with opp

inf, critical care without nutritional support, chronic organ failure

Protein-Energy Undernutriton Clinical wasting + albumin < 3.5 gm/dl

> 1/3 hospital < 1/3 NH < 10% independent

Big cachexia overlap Nutrition support Treat underlying disease

Failure to Thrive

Not a defined syndrome in the elderly

DETERMINE Screening Tool

D isease E ating poorly T ooth loss, mouth pain E conomic hardship R educed social contacts M ultiple medications I nvoluntary weight loss or gain N eed for assistance in self-care E lderly (age > 80)

DETERMINE Your Nutritional Health Checklist. Nutrtion Screeining Initiative, a project of the American Academy of Family Physicians, the American Dietetic Association, and the National Council on Aging, Inc., and funded in part by Ross Products Division,

DETERMINE Evaluation

Read the statements below. Circle the number in “YES” column for those that apply to you or someone under your care. For each “YES” answer, score the number n the box. Total your nutrition score.

I have an illness or condition that made me change the kind and/or amount of food I eat 2 I eat fewer than 2 meals a day 3 I eat few fruits or vegetables, or milk products 2 I have 3 or more drinks of beer, liquor, or wine almost every day 2 I have tooth or mouth problems that make it hard for me to eat 2 I don’t always have enough money to buy the food I need 4 I eat alone most of the time 1 I take three or more different prescribed or over-the-counter drugs a day 1 Without wanting to, I have lost or gained 10 pounds in the last 6 months 2 I am not always physically able to shop, cook, and /or feed myself 2

Note: Scoring: 0-2 = good, 3-5 = moderate nutritional risk, 6 or more = high nutritional risk

Mini-Nutritional Assessment (MNA) Two Part

3 min screen 8 min diagnostic

Validated against measurable standards Inclusive, Plenary

MNA Part 1 Skill Session

MNA Part 2 Skill Session

MNA Study Results

Oral supplementation in skilled living elderly with MNA 17-23.5 and < 17 with 1 can (400 kcal) significantly increased: calorie intake MNA score about 3 points Weight about 1.5 kg

Alzheimer’s Supplementation at 2 kg weight loss stabilizes

weight loss compared to controls

Food Pyramids

MyPyramid.gov Culturally distinct More flexible

MyPyramid.gov

Grains – gold Vegetables – green Fruits – red Oils – yellow Milk – Blue Meats + Beans – Purple Discretionary Calories

< 200 to 300 kcal Exercise

30, 60, 90 rule

Age Specific Recommendations People over age 50.

Consume vitamin B12 in its crystalline form (i.e., fortified foods or supplements).

Older adults, people with dark skin, and people exposed to insufficient ultraviolet band radiation (i.e., sunlight). Consume extra vitamin D from vitamin D-fortified

foods and/or supplement

Nutrient-Nutrient/Drug Interactions Numerous

Ca, Mg, Fe Phytins (in fiber) Tannins (coffee, tea)

Bind drugs/nutrients Bind drugs/nutrients Bind drugs/nutrients

Drug-Nutrient Interactions I

Alcohol Antacids Antibiotics Colchicine Digoxin Diuretics Isoniazid Levodopa Laxatives

Zn, A, B1, B2, B6, B12, folate

B12, folate, Fe, kcal K B12

Zn, kcal Zn, Mg, B6, K, Cu

B6, niacin

B6

Ca, A, B2, B12, D, E, K

Drug-Nutrient Interaction II

Lipid Binding Resins Metformin Mineral Oil Phenytoin Salicylates SSRI Theophylline Trimethoprim

A, D, E, K B12, kcal A, D, E, K D, folate C, folate Kcal Kcal folate

Nutrient Treatment of Disease Ca and Vit D for osteoporosis B6, B12 for homocysteinosis Antioxidants CAD, Macular Degeneration Vitamin E failed for AD Watch for overdosing of vitamins!

Case Phase 2 – Outpatient Treatment She responds to in-home physical therapy

after a steroid injection of her L shoulder. She starts to eat breakfast and uses a supplement when her appetite is poor. Meals on wheels brings her one meal a day. She eats with a friend who cooks every Tuesday at lunch. She gains back 7 pounds.

Case Phase 2 : Hospital Evaluation Your patient falls and breaks her left hip. She

survives a L total hip replacement, but develops pyelonephritis with bacteremia at the hospital. She is delirious. She loses 15 pounds.

What do you do now?

Nutrition Requirement Calculations 1 Estimated Energy Needs by Weight

25-30 kcal / kg body weight / day Use 120% IBW for obese persons

Estimated Protein Needs by Weight Protein = (0.8-1.5) gm / kg body weight / day Use IBW for obese persons May need to be higher (2.0-3.0) for stressed and

or very malnourished persons.

Nutrition Requirement Calculations 2 Harris-Benedict Basal Estimated Basal

Energy Expenditure (BEE) Male BEE = 66 +(13.7 x weight in kg) + (5 x

height in cm) – (4.7 x age) Female BEE = 665 +(9.6 x weight in kg) + (1.8 x

height in cm) – (4.7 x age) Multiply by 1.00 (non-stressed) to 1.50 (stressed)

Laboratory Evaluation

Albumin < 3.8 g/dl Lacks sensitivity and specificity May decline very slightly with age Negative acute phase reactant

Prealbumin Shorter half-life than albumin No more predictive

Cholesterol < 160 mg/ml Indicates underlying serious disease in community, hospital

and NH patients Total Lymphocyte Count < 2000 cells/microliter

Tube Feeding

3-7 days of 1-2 kcal/ml supplement Convert to PEGE for “long term” use

1500-2400 ml per day to achieve water, protein, calorie goals Start full strength, increase rate Measure residuals, convert to bolus feeds

Supplement enzymes Treat diarrhea Deal with aspiration

TPN

For non-functioning GI tract No EMB studies in elders

Case Phase 2: Hospital Treatment After pulling out her NG tube every shift for

24 hours, she is given TPN through her central line. After 48 hours, she is dyspneic, hypoxic, and edematous.

What do you do now?

Re-feeding Syndrome

Syndrome of hypophosphatemia hypomagnesemia fluid retention about 3 days into re-feeding

Most pronounced with parenteral nutrition Occurs with oral re-feeding as well

More severe with worse malnutrition Frequent subclinical presentation Reduce re-feeding rate for three days to treat

Case Phase 3: Skilled Facility Evaluation She recovers from bacteremia, and since she

cannot tolerate a rehab schedule due to residual delirium and weakness is placed in skilled care. While there, she does poorly in PT/OT. Has restricted diet order for CHF. On narcotics, anxiolytics. She is depressed, constipated, requires 1-2 person assists for ADL’s. She has no appetite.

Anorexia

Drugs Anemia Uremia Liver Disease Dry Mouth Pain

Cancer Inflammation Psychiatric Illness Bowel Disease Constipation Malnutrition

Anorexia : Appetite Stimulation Food Appearance Salt Sugar Social Contact Feeding Ambience Familiarity Drugs Ghrelin, other hormones

Anorexia : Pharmacologic Support Mirtazipine

probably works Cannabis, Cannabinoids, Tetrahydrocannabinol and its derivatives

No therapeutic effect or use in medicine Ritalin

Unsure, probably in depression Estrogens/Progestins/Thalidomide

Probably risk of DVT is too high for routine use Corticosteroids

Especially in cancer, hematologic, neurologic Prokinetics Cyproheptadine Hydrazine sulphate – no utility Dronabinol Antiserotonergic drugs Branched-chain amino acids, Eicosapentanoic acid Melatonin

Sarcopenia of the Elderly

Age related loss of skeletal mass Type I fibers spared Type II loss of number and size

Questions: Sedentary Dietary Hormonal Neurologic Sex hormonal

Case Phase 4

Recovers

ICD-9 Codes

Malnutrition 1st degree (mild) 263.1 2nd degree (moderate) 263.0 3rd degree (severe) (protein calorie) 262 From neglect 995.84 Causes problems for NH

Hypoalbuminemia / Hypoproteinemia 273.8 Protein Deficiency / Kwashiorkor 260 Marasmus 261

Causes problems for NH Senile Marsmus 797 Intestinal Marasmus 569.89 Lack of Food 994.2 Nutritional Deficiency, particular, specify 269.9 Undernourishment/Undernutrition 269.9 Weight loss (cause unknown) 783.21 Failure to thrive 783.7

Causes problems for NH

Treatment of Malnutrition

Ease dietary restrictions Supplements

Foods Enhanced Milk or Soy based products

Drugs Supportive Therapies

Summary

Malnutrition is prevalent in the elderly Reproducible assessment is available Intervention prevents morbidity and mortality Supplements have a role in therapy

Bibliography

Cobbs EL, Dithie EH, Murphy JB, eds. Geriatrics Review Syllabus: A Core Curriculum in Geriatrics Medicine. 5th ed. Malden, MA: Blackwell Publishing for the American Geriatrics Society; 2002.

MyPyramid.gov United States Department of Agriculture Screening for Obesity in Adults. What's New from the USPSTF? AHRQ Publication No. 04-IP002, December

2003. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/3rduspstf/obesity/obeswh.htm

http://www.mna-elderly.com/ Cornali, Cristina, Franzoni, Simone, Frisoni, Giovanni B. & Trabucchi, Marco (2005)

ANOREXIA AS AN INDEPENDENT PREDICTOR OF MORTALITY.Journal of the American Geriatrics Society 53 (2), 354-355.doi: 10.1111/j.1532-5415.2005.53126_4.x

Visvanathan, Renuka, Macintosh, Caroline, Callary, Mandy, Penhall, Robert, Horowitz, Michael & Chapman, Ian (2003)The Nutritional Status of 250 Older Australian Recipients of Domiciliary Care Services and Its Association with Outcomes at 12 Months.Journal of the American Geriatrics Society 51 (7), 1007-1011.doi: 10.1046/j.1365-2389.2003.51317.x

http://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl2.htm

Persson, Margareta D., Brismar, Kerstin E., Katzarski, Krassimir S., Nordenström, Jörgen & Cederholm, Tommy E. (2002) Nutritional Status Using Mini Nutritional Assessment and Subjective Global Assessment Predict Mortality in Geriatric Patients. Journal of the American Geriatrics Society 50 (12), 1996-2002.doi: 10.1046/j.1532-5415.2002.50611.x

Journal of the American Geriatrics SocietyVolume 52 Issue 10 Page 1702  - October 2004doi:10.1111/j.1532-5415.2004.52464.x

Bibliography

Hematol Oncol Clin North Am. 2002 Jun;16(3):589-617.Related Articles, Links

Update on anorexia and cachexia.

Strasser F, Bruera ED.

Department of Palliative Care and Rehabilitation Medicine, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Box 0008, Houston, TX 77030, USA

Cancer Surv. 1994;21:99-115.Anorexia and cachexia in advanced cancer patients.

Vigano A, Watanabe S, Bruera E.

Palliative Care Program, Edmonton General Hospital, Canada.CA Cancer J Clin. 2002 Mar-Apr;52(2):72-91.

                       Cancer anorexia-cachexia syndrome: current issues in research and management.

Inui A.

http://www.bccancer.bc.ca/PPI/UnconventionalTherapies/HydrazineSulfateHydrazineSulphate.htm